Informed Consent for Flexible Sigmoidoscopy

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23560 Madison Street, Suite 211 Torrance, CA 90505 Phone: (310) 539-2055 - Fax: (310) 530-3263 INFORMED CONSENT FOR FLEXIBLE SIGMOIDOSCOPY 1. I,__________________________________________________________________authorize Dr. ___________________________________ and any assistant(s) he/she deems necessary to perform Sigmoidoscopy with possible biopsy and/or possible removal of polyp, and other ____________________________________________________________. 2. I understand this procedure involves the following: Passage of fiber optic instrument through the rectum to allow the physician to visualize the interior of my lower portion of my large intestine (colon). 3. RISKS: Possible complications of this procedure include but are not limited to: Bleeding, tearing or perforation of the bowel wall. These complications, should they occur, may require surgery and/or a transfusion (Estimated 1 per 10,000 procedures). Other risks which can be serious and possibly fatal include: difficulty in breathing, heart attack and stroke. These risks are extremely rare but may occur. 4. I understand that there are no guarantees regarding the results of this procedure. Alternatives are_______________________________________________________________________ ______________________________________________________________________ ____. 5. ALTERNATIVES: Liver tissue for diagnostic examination can also be obtained by looking into the abdominal cavity with a scope, which is called laparoscopy, by surgery and by radiology by threading a needle through a neck vein. 6. ANESTHESIA: A medicine causing numbness will be injected at the site of the biopsy. Sometimes an intravenous sedative will be given as well. No general anesthesia is needed. Witness Patient/Responsible Party Date/Time 7. PHYSICIAN DECLARATION: I have explained the contents of this document to the patient and have answered all the patients questions. To the best of my knowledge, I feel the patient has been adequately informed and has consented. Physicians Signature Date/Time.

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Flexible Sigmoidoscopy with Haemorrhoid Banding
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The Costs and Benefits of Moving to the ICD-10 Code Sets
CHILDREN AND ADOLESCENTS This PDF document was made available from www.rand.org as a public CIVIL JUSTICE service of the RAND Corporation. EDUCATION ENERGY AND ENVIRONMENT Jump down to document HEALTH AND HEALTH CARE 6 INTERNATIONAL AFFAIRS POPULATION AND AGING The RAND Corporation is a nonprofit research PUBLIC SAFETY SCIENCE AND TECHNOLOGY organization providing objective analysis and effective SUBSTANCE ABUSE solutions that address the challenges facing the public TERRORISM AND HOMELAND SECURITY and private sectors around the world. TRANSPORTATION AND INFRASTRUCTURE U.S. NATIONAL SECURITY Support RAND Purchase this document Browse Books & Publications Make a charitable contribution For More Information Visit RAND at www.rand.org Explore RAND Science and Technology View document details Limited Electronic Distribution Rights This document and trademark(s) contained herein are protected by law as indicated in a notice appearing later in this work. This electronic representation of RAND intellectual property is provided for non-commercial use only. Permission is required from RAND to reproduce, or reuse in another form, any of our research documents for commercial use. This product is part of the RAND Corporation technical report series. Reports may include research findings on a specific topic that is limited in scope; present discus- sions of the methodology employed in research; provide literature reviews, survey instruments, modeling exercises, guidelines for practitioners and research profes- sionals, and supporting documentation;
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